STI Report

Fuchia ID:

Gender:

Reg_Age/Cur Age:

Risk Factor:

General ID & Visit Date

Clinic @php $stiClinicRaw = (string) (Auth::user()->clinic ?? ''); preg_match('/\d{2,3}/', $stiClinicRaw, $stiClinicMatch); $stiClinicCode = $stiClinicMatch[0] ?? $stiClinicRaw; @endphp

First Visit

If Last Visit

Heard about clinic

Reasons For Visit

History

Urethral Discharge How long Abnormal vaginal discharge

Yes

How Long Linked with menstruation Amount Colour Other(Specify) Abnormal vaginal odour

Lower abdominal pain How Long Fever Recent Termination Pregnancy Dyspareunia Other GI Symptoms

Dysuria How many days

Genital Pruritis How long

Genital burning or Pain How long

Genital ulcer How Long Pain Single/Multiple Ulcer Prodormal itch/burning Started as vesicles /blisters Recurrent Last Episode(Month ago) Patient Suspects Herpes

Inguinal lymph node How long Unilateral/Bilateral Other lymph nodes? Leg ulcer/other infection

Scrotal Swelling How long Tender/ Non-Tender

Genital Warts How long

Physical Exam

Urinated within < 1 hour before visit Washed inside < 1 hour

Yes

Discharge Discharge after milking Colour

Erythema on glans Blisters on Penis

Vulvar erythema Vulvar oedema

Vaginal Discharge Amount Homogeneous Colour Smell(Without KOH) Vaginal wall injury

Endocervical mucopus Colour Cerv.motion tenderness

Adnexal tenderness Adnexal enlargement

Genital blisters Location

Genital ulcer Esitimated size(cm diameter) Location Signle/Multiple Painful/Painless Herpes suspected

Inguinal bubo Fluctuant Tender/non tender Other Leg infection

Genital Warts Crab lice Scabies

Scrotal Swelling Esitimated Size(cm diameter) Unilateral/bilateral Tender/Non-Tender Erythema

KOH smell test pH Vagina

Making drawing and describe the size

STI follow up History

Serial No.	Clinic Code	Gender	Age	Risk Factor	Visit Date

RPR Test History

No.	Row-ID	Visit Date	RPR Result

Search Data in STI Register and Update

General ID

No.	Visit Date

STI Entry

History

Treatment (Fill in dose)

Counselling (mark topic discussed)

STI follow up History

RPR Test History

Search Data in STI Register and Update

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